Bodyscapes Patient Form

Bodyscapes Patient Form

Please complete all twelve sections of this form (20-25 minutes) and click "Submit". If you wish to save and continue the form later, click "Save" (located at each page break). A pop up box from Jotform will appear. Input your email. You will receive an email with your form to complete at your convenience.
Date

Month Day Year
1. General Information
Name

First Name Last Name
Date of birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Emergency contact and phone number
How did you hear about Bodyscapes?
Have you ever received acupuncture before?

9. Physical Activity
Do you exercise? How frequently and for what duration?
What types of exercise?
Do you like to exercise?
What kind of work do you do? Hours per week?
How many hours do you spend at the computer daily?
How many hours of TV you watch daily?
What physical activities do you enjoy (walking, swimming, yoga, etc.)?
Are there any reasons and/or conditions that prevent you from exercising regularly? Please specify:

10. Diet and Nutrition
How is your appetite and how many meals do you eat daily?
How often do you have a bowel movement?
Are you thirsty and how much water do you drink per day?
Do you prefer cold or hot beverages?
Do you drink caffeine and how much daily?
List other beverages you drink including juice, rice milk, almond milk, tea, etc?
What dairy products do you eat/drink?
Are you a vegetarian or vegan? Please list sources of protein:
What percentage of your diet is organic:
Do you have any particular cravings?
List any food allergies or sensitivities:
Do you eat regularly at fast food restaurants?
How often do you eat out?

Every day Frequently On occasion Rarely
Do you eat a lot of processed food?
Do you eat late at night or before going to bed?
Do you chew your food well?
Do you think you get enough fresh fruits, vegetables, and whole grains daily?
Do you drink alcohol and how much?
Do smoke cigarettes and how many daily?
Do you take any other recreational drugs?
How would you describe your diet:

Unhealthy Fair Good Excellent
On a scale of 1 to 10 (10 being best), how would you rate your cooking skills:
Are you ready and willing to make changes to your diet if need be?

11. Men's Health
Check all that apply to you:

Erectile dysfunction Low libido Testicular pain Premature ejaculation STD Prostrate issues Infertility Varicocele
Any other issues I should be aware of? Please specify:

6. Stress Level